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Active management of the third stage of labor is recommended for preventing postpartum hemorrhage (PPH). However, the specific effects of each of its components have not been adequately evaluated. The TRACOR Study aimed to assess the impact of controlled cord traction on the incidence of PPH and other characteristics of the third stage of labor, in a high-resource setting.
Randomized controlled trial conducted between 01/2010 and 01/2011 in 5 French university hospitals. 4058 women aged ≥18, with a planned vaginal delivery, at a gestational age ≥35 weeks, with a singleton fetus were randomly assigned to have third stage of labor managed either by controlled cord traction (CCT) or by standard placenta expulsion (SPE) i.e. awaiting the spontaneous placental separation before facilitating its expulsion. Prophylactic oxytocin just after birth was administered in the 2 arms. The primary outcome was the incidence of PPH ≥500 mL as measured in a collector bag.
The incidence of PPH was not different in the CCT (9.8% (196/2005) and in the SPE (10.3% (206/2008) groups, RR 0.95, 95% CI (0.79 to 1.15). The need for manual removal of placenta was significantly less frequent in the CCT than in the SPE group (4.2%(85/2033) and 6.1%(123/2024), RR 0.69, 95%CI (0.53 to 0.90)); as was third stage > 15 min (4.5% (91/2030) and 14.3% (289/2020), RR 0.31, 95%CI 0.25 to 0.39)). Women in the CCT group reported a significantly lower intensity of pain and discomfort during the third stage than those in the SPE group. No uterine inversion occurred in either arm.
Controlled cord traction does not decrease the incidence of PPH. However, in hospital settings where deliveries are managed by trained clinicians, the benefit/harm balance of controlled cord traction is in favor of its integration in routine practice as it is safe and results in shorter duration of third stage, less need for manual removal of placenta, and higher satisfaction of women.